Healthcare Provider Details

I. General information

NPI: 1841263472
Provider Name (Legal Business Name): KELLY FABIAN PT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 BRIDGEBORO RD
DELRAN NJ
08075-9700
US

IV. Provider business mailing address

16 EVERGREEN RD
MOUNT LAUREL NJ
08054-2173
US

V. Phone/Fax

Practice location:
  • Phone: 856-764-0494
  • Fax: 856-764-0580
Mailing address:
  • Phone: 856-802-1218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00922100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: